Approved, SCAO JIS CODE: DSP STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY ORDER OF DISPOSITION, OUT-OF-HOME (DELINQUENCY PROCEEDINGS), PAGE 1 CASE NO. PETITION NO. Court address Court telephone no. ORI MI- CTN/TCN SID DOB 1. In the matter of name(s), alias(es) 2. Date of hearing: Judge/Referee: Bar no. 3. Notice of hearing for the disposition was given as required by law. 4. The juvenile has appeared in court in person with parent(s), guardian, legal custodian, guardian ad litem, and was represented by an attorney. waived representation by an attorney. 5. An adjudication was held and the court determined that the juvenile committed the following offense(s) and/or the following offense(s) has/have been dismissed: ADJUDICATED BY DISMISSED BY* Count Plea* Court Jury ALLEGATIONS CHARGE CODE(S) MCL Citation/PACC Code *For plea, insert "A" for admission or "NC" for nolo contendere. For dismissal, insert "D" for dismissed by court or "NP" for dismissed by prosecutor/plaintiff. 6. Specific findings of fact and law regarding this proceeding have been made on the record. 7. HIV testing and sex offender registration are completed. 8. A DNA sample is already on filed with the Michigan State Police from a previous petition. No assessment is required. 9. The juvenile has been fingerprinted according to MCL 28.243. 10. The offense adjudicated is abstractable to the Secretary of State (under MCL 257.625[20][a], MCL 257.732, MCL 324.80131, MCL 324.81134[12], MCL 324.81135[7], MCL 324.82157, or MCL 333.7408a[12]). The juvenile's driver's license number is . 11. The licensing sanction is reportable to the State Police (under MCL 333.7408a[12] or MCL 257.625[20][b]). Revoked. Suspended days. Restricted days. 12. The juvenile must be placed in an institution outside Michigan because a. institutional care is in the best interests of the juvenile, b. equivalent facilities to meet the juvenile's needs are not available within Michigan, and c. the placement will not cause undue hardship. Do not write below this line - For court use only (SEE SECOND PAGE) Upon disposition of a juvenile offense as defined under MCL 28.241a(f), the clerk of the court shall advise the Michigan State Police Criminal Justice Information Center of the disposition as required by MCL 712A.18(11). MCL 28.241a, MCL 600.2950h; 600.2950m, MCL 712A.18; 712A.18k; 712A.20, MCL 764.15b, MCL 769.1f, MCL 769.16a, MCR 3.936, MCR 3.943 JC 14b (6/15) ORDER OF DISPOSITION, OUT-OF-HOME (DELINQUENCY PROCEEDINGS), PAGE 1 American LegalNet, Inc. www.FormsWorkFlow.com Approved, SCAO JIS CODE: DSP STATE OF MICHIGAN JUDICIAL CIRCUIT - FAMILY DIVISION COUNTY ORDER OF DISPOSITION, OUT-OF-HOME (DELINQUENCY PROCEEDINGS), PAGE 2 CASE NO. PETITION NO. Court address Court telephone no. In the matter of 13. It is contrary to the welfare of the juvenile to remain in the home because 14. a. Reasonable efforts to prevent removal of the juvenile from the home were not made. b. Reasonable efforts were made prior to the placement of the juvenile in foster or other out-of-home care, to prevent or eliminate the need for removing the juvenile from his/her home. Those efforts include: (Specify.) 15. a. Reasonable efforts shall be made to preserve and reunify the family to make it possible for the juvenile to safely return home. b. Reasonable efforts shall not be made to preserve and reunify the family because it would be detrimental to the juvenile's health and safety. c. Reasonable efforts to preserve and reunify the family were not previously required, but due to a change in circumstances, reasonable efforts are now required. Those reasonable efforts have begun and include: (Specify reasonable efforts, and if applicable, the reasons for return.) The juvenile should be released to . Name(s) of parent(s), guardian, or legal custodian IT IS ORDERED: 16. The juvenile is referred to the Michigan Department of Health and Human Services for placement and care under MCL 400.55(h). 17. Other: (Include reimbursement as required by MCL 712A.18[2] or as permitted by MCL 769.1f.) 18. Juvenile shall pay $ $25.00 for Crime Victim's Rights Fund. State minimum costs DNA assessment (not required if item 8. is checked). 19. The review date is Recommended by: Date . specify for each count . Referee signature Judge *Note: Contrary to the welfare findings (item 13 must be made when the juvenile is initially removed, and if returned home, at any subsequent removal. Reasonable efforts findings (items 14 and 15) must be made within 60 days of the removal of the juvenile from the home, and if returned home, at any subsequent removal. JC 14b (6/15) ORDER OF DISPOSITION, OUT-OF-HOME (DELINQUENCY PROCEEDINGS), PAGE 2 American LegalNet, Inc. www.FormsWorkFlow.com